Vaginal Opacification Research Articles

Diagnostic MRI for deep pelvic endometriosis: towards a standardized protocol?

To assess the diagnostic efficacy of an MRI protocol and patient preparation in detecting deep pelvic endometriosis (DPE). The cohort is from the ENDOVALIRM database, a multicentric national retrospective study involving women who underwent MRI followed by pelvic surgery for endometriosis (reference standard). Two senior radiologists independently analyzed MRI findings using the deep pelvic endometriosis index (dPEI) to determine lesion locations. The study evaluated the impact of bowel preparation, vaginal and rectal opacification, MRI unit type (1.5-T or 3-T), additional sequences (thin slice T2W or 3DT2W), and gadolinium injection on reader performance for diagnosing DPE locations. Fisher's exact test assessed differences in diagnostic accuracy based on patient preparation and MRI parameters. The final cohort comprised 571 women with a mean age of 33.3 years (± 6.6 SD). MRI with bowel preparation outperformed MRI without bowel preparation in identifying torus/uterosacral ligament (USL) locations (p < 0.0001) and rectosigmoid nodules (p = 0.01). MRI without vaginal opacification diagnosed 94.1% (301/320) of torus/USL locations, surpassing MR with vaginal opacification, which diagnosed 85% (221/260) (p < 0.001). No significant differences related to bowel preparation or vaginal opacification were observed for other DPE locations. Rectal opacification did not affect diagnostic accuracy in the overall population, except in patients without bowel preparation, where performance improved (p = 0.04). There were no differences in diagnostic accuracy regarding MRI unit type (1.5-T/3-T), presence of additional sequences, or gadolinium injection for any endometriotic locations. Bowel preparation prior to MRI examination is preferable to rectal or vaginal opacification for diagnosing deep endometriosis pelvic lesions. Accurate diagnosis and staging of DPE are essential for effective treatment planning. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols. Optimizing MRI protocols for diagnostic performance with appropriate opacification techniques will help diagnose deep endometriosis more accurately. Evaluating deep endometriosis in collapsible organs such as the vagina and rectum is difficult. Bowel preparation and an absence of vaginal opacification were found to be diagnostically beneficial. Bowel preparation should be prioritized over rectal or vaginal opacification in MRI protocols.

Value of 3D MRI and Vaginal Opacification for the Diagnosis of Vaginal Endometriosis.

Objective: The aim of the study was to evaluate three-dimensional (3D) T2 MRI before and after vaginal opacification (VO) by gel (3DT2VO) and the additional value of 3DT1 with fat-suppression (3DT1FS) MRI in the diagnosis of vaginal endometriosis.Methods: In this study conducted from 2010 to 2013, 51 patients scheduled for surgical treatment of endometriosis underwent MRI 1 day before surgery. Three readers (novice, intermediate, expert) were asked to retrospectively diagnose vaginal endometriosis independently and blindly using four different readings (i.e., 3DT2, 3DT2VO, 3DT2 with 3DT1FS, 3DT2VO with 3DT1FS). Vaginal endometriosis diagnosis was positive on observation of a thickening of vaginal walls on 3DT2 with or without high-signal-intensity spots on 3DT2 and/or 3DT1FS. The reference standard was surgery and histology. Descriptive analysis, Chi-square test, and ROC curves were used for statistical analysis.Results: For all readers, the combination of 3DT2 and 3DT1FS significantly improved the diagnosis of vaginal endometriosis compared with 3DT2 (p = 0.002, p = 0.02, and p = 0.003). 3DT2VO significantly improved diagnosis for the intermediate reader (p = 0.01). High-signal-intensity spots on 3DT1FS had a sensitivity of 50–63.6%, specificity of 86.2–96.6%, and high positive likelihood ratios (14.5-Inf).Conclusion: 3DT2 in association with 3DT1FS appears to be the best 3D MRI protocol for the diagnosis of vaginal endometriosis, whatever the level of experience of readers. The additional value of 3DT2VO is variable among the readers.

MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature.

Our objective was to establish the primary mode of imaging and MR protocols utilised in the preoperative staging of deeply infiltrating endometriosis in centres accredited by the British Society of Gynaecological Endoscopy (BSGE). The lead consultant radiologist in each centre was invited to complete an online survey detailing their protocols. Out of 49 centres, 32 (65%) responded to the survey. Two centres performed transvaginal ultrasound as the primary method for preoperative staging of deeply infiltrating endometriosis and the remainder performed MRI. 21/25 centres did not recommend a period of fasting prior to MRI and 22/25 administered hyoscine butylbromide. None of the centres routinely offered bowel preparation or recommended a specific pre-procedure diet. 21/25 centres did not time imaging according to the woman's menstrual cycle, and instructions regarding bladder filling were varied. Rectal and vaginal opacification methods were infrequently utilised. All centres preferentially performed MRI in the supine position - six used an abdominal strap and four could facilitate prone imaging. Just under half of centres used pelvic-phased array coils and three centres used gadolinium contrast agents routinely. All centres performed T1W with fat-suppression and T2W without fat-suppression sequences. There was significant variation relating to other MR sequences depending on the unit. There was significant inconsistency between centres in terms of MR protocols, patient preparation and the sequences performed. Many practices were out of line with current published evidence. Our survey demonstrates a need for evidence-based standardisation of imaging in BSGE accredited endometriosis centres.

Deep infiltrating endometriosis: Should rectal and vaginal opacification be systematically used in MR imaging?

ObjectivesTo evaluate the interest of rectal and vaginal filling in vaginal and recto-sigmoid endometriosis with MR imaging. To compare the results between a senior and a junior radiologist review. MethodsSixty-seven patients with clinically suspected deep infiltrating endometriosis were included in our MRI protocol consisting of repeated T2-weigthed sequences (axial and sagittal) before and after rectal and vaginal marking with ultrasonography gel. Vaginal and recto-sigmoid endometriosis lesions were analyzed before and after opacification. The inter-reader agreement between senior and junior scores was studied. ResultsConcerning vaginal and muscularis and beyond colonic involvement, no significant difference (P=0.32) was observed and the inter-reader agreement was excellent (K=0.96 and 0.97 respectively). Concerning serosa colonic lesions, a significant difference was observed (P=0.01) and the inter-reader agreement was poor (K=0). ConclusionsRectal and vaginal filling in endometriosis staging with MRI is not necessary no matter the reader experiment.

Sexual Anatomy and Function in Women With and Without Genital Mutilation: A Cross-Sectional Study.

Female genital mutilation (FGM), the partial or total removal of the external genitalia for non-medical reasons, can affect female sexuality. However, only few studies are available, and these have significant methodologic limitations. To understand the impact of FGM on the anatomy of the clitoris and bulbs using magnetic resonance imaging and on sexuality using psychometric instruments and to study whether differences in anatomy after FGM correlate with differences in sexual function, desire, and body image. A cross-sectional study on sexual function and sexual anatomy was performed in women with and without FGM. Fifteen women with FGM involving cutting of the clitoris and 15 uncut women as a control group matched by age and parity were prospectively recruited. Participants underwent pelvic magnetic resonance imaging with vaginal opacification by ultrasound gel and completed validated questionnaires on desire (Sexual Desire Inventory), body image (Questionnaire d'Image Corporelle [Body Image Satisfaction Scale]), and sexual function (Female Sexual Function Index). Primary outcomes were clitoral and bulbar measurements on magnetic resonance images. Secondary outcomes were sexual function, desire, and body image scores. Women with FGM did not have significantly decreased clitoral glans width and body length but did have significantly smaller volume of the clitoris plus bulbs. They scored significantly lower on sexual function and desire than women without FGM. They did not score lower on Female Sexual Function Index sub-scores for orgasm, desire, and satisfaction and on the Questionnaire d'Image Corporelle but did report significantly more dyspareunia. A larger total volume of clitoris and bulbs did not correlate with higher Female Sexual Function Index and Sexual Desire Inventory scores in women with FGM compared with uncut women who had larger total volume that correlated with higher scores. Women with FGM have sexual erectile tissues for sexual arousal, orgasm, and pleasure. Women with sexual dysfunction should be appropriately counseled and treated.

The G-spot: an observational MRI pilot study.

To identify a G-spot complex (GSC) in vivo in MRI examinations at 1.5 Tesla field strength. Observational study. Single centre. Twenty-one consecutive patients (January-March 2014). Imaging analysis of routine imaging protocols for usual medical indications with and without concomitant opacification of the vaginal cavity with inert ultrasound gel. The gel distends the otherwise collapsed vaginal walls, allowing for an improved discrimination of anatomic features. The macroscopic and histological results recently derived from the dissections of fresh cadavers by Ostrzenski et al. were translated into imaging characteristics to be expected in the respective MRI sequences (e.g. T1- and T2-weighted) in search of an in vivo correlate of the GSC. Age, menopause status, medical indication and diagnosis were co-variables. To analyse primarily whether MRI imaging is able to depict a distinct morphological entity in vivo matching the GSC, based on anatomical descriptions published recently. The elaboration of an appropriate MRI-imaging protocol was a secondary aim. A total of 21 studies were obtained. A GSC was identified within the anterior vaginal wall in 13/21 patients (62%). In all, 10/21 (48%) had vaginal gel opacification. We identified a GSC in 10/10 patients (100%) with opacification in all three planes of the T2 images. This was only true for 3/11 cases (27%) without opacification. There is evidence for an in vivo morphological correlate to the postmortem anatomical findings of a GSC described by Ostrzenski et al.; its visibility in MRI imaging can be significantly improved with vaginal opacification by ultrasound gel. Identification of G-spot by MRI with vaginal gel-opacification in 13/21 patients.

Deeply infiltrating endometriosis: Evaluation of retro-cervical space on MRI after vaginal opacification

ObjectivesTo prospectively investigate diagnostic value and tolerability of MRI after intra-vaginal gel opacification for diagnosis and preoperative assessment of deeply infiltrating endometriosis. MethodsSixty-three women with clinical suspicion of deeply infiltrating endometriosis were previously examined with trans-vaginal ultrasonography and then with MRI pre and post administration of vaginal gel. We evaluated the tolerability of this procedure with a scoring scale from 0 to 3. We also assessed with a score from 1 to 4 the visibility of four regions: Douglas-pouch, utero-sacral-ligaments, posterior-vaginal-fornix and recto-vaginal-septum. All patients underwent laparoscopic surgery after MRI. ResultsFive patients considered procedure intolerable. Visibility of utero-sacral-ligaments and posterior-vaginal-fornix showed to be increased with gel (p<0.001). In 57 out of 80 patients the MRI has allowed us to diagnose deeply infiltrating endometriosis.Overall, the percentages of MRI-sensitivity, specificity, positive predictive value and negative predictive value were respectively 67.8%, 95.3%, 89.4 and 83.5% without gel, and 90.8%, 94.6%, 90.8% and 94.6% with gel; trans-vaginal ultrasonography sensitivity, specificity, positive predictive value and negative predictive value were 57.5%, 96.6%, 90.9% and 79.5%.In evaluation of utero-sacral-ligaments trans-vaginal ultrasonography, MRI without gel and with gel sensitivity was respectively 61.9%, 47.6% and 81%; for recto-vaginal-septum these values were 12.5%, 68.7% and 93.7%; for pouch of Douglas 82%, 87% and 97.4%; finally for posterior-vaginal-fornix 27.3%, 36.4% and 81.8%. ConclusionsMRI with gel opacification of vagina should be recommended for suspicion of deep infiltrating endometriosis, in particular for the added value in evaluation of recto-vaginal septum, utero-sacral ligaments and posterior vaginal fornix.

Anatomie pelvienne en IRM : apport du contraste vaginal

Prospective monocentric study to determine the feasibility, tolerability and diagnostic value of intravaginal contrast to assess female pelvic anatomy on MRI. Forty-nine consecutive women referred for MRI evaluation of the pelvis, irrespective of the indication, were included in this study. The MR imaging protocol consisted of axial and sagittal T2W images before and after intravaginal instillation of sterile US gel. Eight anatomical regions were analyzed and their visibility graded from 1 to 4 (1=excellent; 4=non-visualized) by 3 radiologists without and with intravaginal gel. The value of intravaginal gel was determined by calculating the difference in the visibility index for each anatomical region by the Wilcoxon and khi2 tests. Inter-observer agreement was also determined using the kappa test. Two women declined vaginal opacification resulting in an acceptance rate of 96%. The gel instillation procedure had a duration of less than 3 minutes on average and was well tolerated by all patients. Intravaginal gel allowed significantly improved visualization of all anatomical regions (p<0.001); improvement between 0.5 and 2.5 points on average per anatomical region. Inter-observer agreement significantly improved after gel instillation increasing from 72% to 92%. Intravaginal instillation of US gel is simple, noninvasive, well-accepted and well-tolerated by patients. It increases visibility of pelvic anatomical structures with improved inter-observer agreement.

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation

The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC). Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured. Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation. Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.

Efficacy of transvaginal contrast-enhanced MRI in the early staging of cervical carcinoma

The objective of this study was to evaluate the efficacy of transvaginal contrast for local staging of cervical carcinoma. Fifty patients diagnosed with cervical carcinoma prospectively underwent magnetic resonance (MR) imaging before and after vaginal opacification (VO) with a mixture of 25 ml saline and 25 ml barium. T2-weighted (T2W) TSE images in axial and sagittal planes were compared before and after vaginal opacification. Dynamic T1W images in sagittal and fat-suppressed T1W images in transverse planes were also evaluated after intravenous contrast administration. Involvement of vaginal wall, lumen, and fornices; parametrium; rectum; and bladder were noted. Changes in local tumor staging and in treatment planning were also assessed after vaginal opacification. MR results were later compared with surgical pathological findings. Twenty-eight patients who went through surgical staging were included in the study. VO did not change any of the MR interpretations in 14 patients (50%). Correct staging was achieved with T2W TSE images with and without VO (in sagittal and transverse planes) in 78.5% and 50% of the patients, respectively. VO correctly lowered staging in seven and increased it in three patients compared with sagittal standard T2W images. Treatment planning was also changed in four (14%) of these patients. When overall accuracy of MR staging to indicate the appropriate treatment was evaluated, patients would have received the proper treatment in 90% and 79% of the cases when only T2W sagittal images with and without VO were evaluated, respectively. Dynamic gradient-echo images in sagittal planes and postcontrast T1W images in transverse planes evaluated with T2W series after VO, accomplished correct staging in 23 (82%) of the patients. MRI staging in early cervical cancer may be difficult and overestimated, especially if the tumor is slightly extended into the proximal vagina. Use of vaginal contrast medium is an easy, well-tolerated, and effective method to better delineate the borders of the tumor. It increases the specificity and accuracy of MR staging by showing the exact relation of the tumor with the vaginal wall and beyond.

Defecography in symptomatic older women living at home.

complaints of defecation disorders in older patients living at home is an emerging problem. Little is known about radiological examination of this population. this study aimed to analyse the yield of defecography in women older than 75 years, living at home and complaining of defecation disorders. prospective study of patients referred to a radiology department in a tertiary-care medical centre in Rouen, France. 52 women (mean age: 78, range: 75-93) complaining of constipation, faecal incontinence or pelvic pain underwent defecography. Defecography was performed after intake of a barium meal and vaginal opacification. Radiographs were analysed accordingly with the established criteria. defecography showed perineal descent in 27 patients, rectocele in 29, intussusception in 33 and enterocele in 14. A combination of abnormalities was found in 40 women. Only 3 studies were normal. There was no significant association between symptoms and pelvic disorders revealed by defecography. defecography in symptomatic women aged 75 years and over did not raise any technical difficulty. It revealed a 77% rate of abnormalities, but there was no relationship between the symptoms and the detected abnormalities.

Vaginal opacification during defecography: utility of placing a folded gauze square at the introitus.

We evaluated the value of placement of a folded gauze square into the urogenital introitus to improve vaginal opacification in 90 patients who underwent defecography. Of the 50 patients who retained the gauze in the introitus, 96% demonstrated excellent or good vaginal opacification. By contrast, only 75% of the 40 patients who lost the gauze during the study were able to achieve the same level of opacification. This difference was shown to be statistically significant (p < 0.002), suggesting that placement of a folded gauze square in the introitus limits loss of contrast from the vagina, which improves vaginal opacification.

Vaginal opacification during defecography: direction of vaginal migration aids in diagnosis of pelvic floor pathology.

To determine whether direction of vaginal displacement during defecography aids in diagnosing pelvic floor pathology. Ninety patients underwent defecography over a 2-year period. Each study was retrospectively reviewed by three radiologists who recorded whether the vagina was displaced cephalad, caudad, or nondisplaced in relation to the urogenital hiatus. This information was then correlated with radiologic diagnosis rendered for the study. Of the 26 patients with normal defecograms, 19 (73%; p < 0. 001) demonstrated no vaginal displacement during the procedure. Comparatively, 10 (83%; p < 0.001) of the 12 patients with cystoceles showed caudad vaginal displacement, and no patients with cystoceles showed cephalad displacement of the vagina. Of the 17 patients with rectoceles, 10 (58%) showed cephalad displacement, one (6%) showed caudad displacement, and six (35%) patients showed no vaginal displacement. Thirteen (46%) of 28 patients with enteroceles showed cephalad vaginal displacement, nine (32%) showed no vaginal displacement, and six (21%) demonstrated caudad displacement. Caudad displacement of the opacified vagina suggests the presence of a cystocele. Cephalad vaginal displacement is suggestive of the presence of an enterocele or rectocele.

10 Dynamic rectal examination (defecography)

Dynamic rectal examination (DRE), first described in 1952, is becoming more widely used in the dynamic evaluation of pelvic floor and anorectal motility disorders. It is a minimally invasive investigation which is well tolerated by patients and provides information about the anosphincteric, puborectal and levator muscle in addition to insight in rectal function and structure. DRE is the only investigation of anorectal function that can give detailed anatomical information such as the presence of a rectocele, an enterocele and an intussusception. DRE should be performed in a quiet environment with a minimum number of investigators present. Any technique which attempts to study the defecatory mechanism must be a compromise since the patient is aware of being studied. In order to defecate on command the radiologist must make the patient comfortable before starting the investigative procedures to avoid any possible psychological inhibition. We have not encountered any failures in this regard. The relative value of the radiological findings with respect to symptoms and complaints is insufficiently known. This has been the main incentive to design carefully and carry out a large prospective critical evaluation of various aspects of DRE in particular the correlation with objective findings and symptoms. Moreover an assessment has been made of its overall clinical utility (Wiersma, 1994). It is very likely that DRE is both investigator- and technique-dependent. To ensure that the study is as physiological as possible the contrast medium used to fill the rectum needs to be semi-solid and malleable equivalent in consistency to a normal faecal bolus. For proper anatomical studies in females vaginal opacification is mandatory. The acceptance of vaginal contrast was good. Only 4% of the female patients preferred not to have the vaginal application of contrast. The technique of DRE when performed with small bowel and vaginal opacification provides a sensitive and objective method of detecting enteroceles. A substantial number of female patients related the onset of their complaints to hysterectomy. In female patients with constipation there was a significantly higher incidence of enteroceles in patients with a hysterectomy compared to the group of females without hysterectomy. Because of these findings a series of pre- and postoperative DREs in hysterectomy patients are on their way in our institute. Unlike a rectocele which is usually most obvious during defecation, enteroceles are sometimes appreciated only with repeated straining after evacuation. It is therefore important to instruct the patient to continue to strain after evacuation to maximize the chance for detection of enteroceles at DRE. Chronically increased intra-abdominal pressure from any cause may lead to enterocele formation whether or not the cul-de-sac has been exposed at prior pelvic surgery. We showed that DRE has an important role in enterocele detection prior to the performance for surgery. The term rectal prolapse is not accurately defined in the literature. The most commonly used definition is a condition where the rectal wall protrudes partially or completely through the anal orifice. The introduction of techniques involving radiological visualization of rectal voiding as used in our studies, however, has necessitated a reappraisal of the definition of rectal prolapse. The rectal prolapse used to be considered to be an extraanal intussusception. By using oral contrast routinely in DRE we were able to visualize a spectrum of severity of enteroceles. Four patients showed enteroceles which protruded through the anal canal leading to a rectal prolapse. None of our patients showed an extra-anal intussusception. All rectal prolapses in our series were caused by huge enteroceles. DRE is mandatory in the pre-operative work up to detect the cause of the rectal prolapse (enterocele or intussusception) if a patient is to be surgically treated.

Colpocystodefecography.

To assess, in one single procedure, a complete study of the female pelvis, including the Douglas pouch. Colpocystodefecography (CCD) combines vaginal opacification, voiding cystography, and defecography. Three hundred examinations are reviewed. Thanks to the simultaneous visualization of the pelvic structures, CCD proved to be more useful than clinical evaluation to diagnose prolapses and particularly Douglas pouch hernias (enteroceles), the clinical diagnosis of which was missed in 93 of 111 cases. Moreover, in addition to morphologic and functional information, CCD brings about a new insight in the study of pelvic organs reciprocal influences, should they be positive (supporting function) or negative (external compression). Finally, significative pelvic surgery and particularly hysterectomy enhances greatly the risk of enteroceles. CCD is helpful in the preoperative staging, especially in the selection of the surgical procedure that will least likely predispose to possible late postoperative complications such as vaginal prolapses or enteroceles.